Pre-operative Covid-19 Screening Referral form for pre-operative Covid-19 testing via Gloucestershire Health and Care NHS Foundation Trust Referral informationType of referral * REQUIREDPre-procedurePre-placementVulnerable patient, not suitable for Pillar 2 testingOtherThis is a drop down boxDate of procedure or placement (TCI) - must be dd/mm/yyyy format * REQUIRED DD slash MM slash YYYY The test will take place 72 hours before this dateLocation of this procedure or placement * REQUIRED Any additional information regarding swab date, location etcWho's activity? * REQUIREDGloucestershire Health and Care NHS FTGloucestershire Hospitals NHS FTGP careIn healthOtherThis is a drop down menu. Which organisation is providing care for this patient? This may be different to the location of the procedure or placement.Which division? * REQUIRED Medical Surgical Referer informationName * REQUIRED First Last Email * REQUIRED Phone * REQUIREDEmail address of referrer * REQUIRED The referrer is the person completing this formPatient's informationPatient's Name * REQUIRED First Last Date of birth * REQUIRED Day Month Year Address * REQUIRED First line of address Post Code Patient's NHS number * REQUIRED Patient's contact number * REQUIREDThis is the number we will use to arrange the testDo you have any additional information that would help with this referral?